Jennifer Liang

Serrated polyp detection rate during screening colonoscopy

Aim  The adenoma detection rate is an important quality indicator for colonoscopy, but recently, serrated polyps of the large bowel have been recognized as important premalignant lesions. As they are often more difficult to see than adenomas, the detection rate of serrated polyps is set to become a more stringent indicator of quality in colonoscopy than adenoma detection rate. Here we aim to provide preliminary data on serrated polyp detection.

Importance of serrated polyps in colorectal carcinogenesis

Colorectal cancer is an invasive neoplasm of the glandular epithelium of the colon and rectum that begins in a precursor lesion and expands to replace its lesion of origin. The majority of colorectal cancers arise from an adenoma, and the ‘adenoma to carcinoma’ pathway has been acknowledged for decades. More recently, another precursor lesion has been recognized: the serrated polyp. Serrated polyps are characterized by a sawtooth appearance of the crypt epithelium resulting from failure of apoptosis and a build‐up of aging colonocytes. Although initially felt to be innocent of involvement in colorectal carcinogenesis, some types of serrated polyp are being increasingly recognized as precursor lesions, prone to develop into cancer, and likely to be a cause of ‘missed’ or interval cancers after colonoscopic screening. It is essential that gastrointestinal specialists appreciate the clinical significance of these lesions and what that means for colorectal cancer screening, and prevention. The purpose of this review is to highlight the importance serrated lesions of the colon and rectum, and to summarize current opinion on their natural history, diagnosis, surveillance and treatment.

Lateral internal sphincterotomy for surgically recurrent chronic anal fissure.

BACKGROUND Lateral internal sphincterotomy cures chronic anal fissure by preventing internal sphincter hypertonia. However, cutting sphincter predisposes to sphincter dysfunction, manifests as incontinence of gas, liquid, or stool. Surgeons, therefore, can be too cautious in its use, making ineffective superficial incisions or avoiding the operation altogether. This study is designed to confirm the role of redo lateral internal sphincterotomy in the treatment of surgically recurrent chronic anal fissure. METHODS Patients undergoing repeat lateral internal sphincterotomy for surgically recurrent chronic anal fissure were accessed from a prospectively maintained database. Chronicity was defined by symptoms persisting more than 3 weeks. Contralateral sphincterotomy was performed with electrocautery through a stab incision over the intersphincteric plane. The length of sphincter division was the same as the length of the fissure. Phone questionnaire was administered and fecal continence was assessed by modified Cleveland Clinic Incontinence Score. Patients were asked to rank their overall satisfaction with the operation, and pre- and postoperative quality of life. RESULTS There were 57 patients, 24 women and 33 men; mean age was 47.9 ± 14.8 years. Mean follow-up was 12.5 ± 4.2 years (range 6.2 to 25.2 years). Presenting symptoms included pain (100%), bleeding (80%), pruritus ani (39%), constipation (26%), and diarrhea. Fifty patients (90%) presented with 1 fissure, and 40 were posterior. Most procedures were performed on an outpatient basis. Fissure healing rate was 98%, and 2 patients (4%) developed minor incontinence postoperatively (one of gas, the other, gas and seepage). Overall satisfaction was 9.7 ± .9 out of 10 with a significant improvement in the quality of life from 5.7 ± 2.4 out of 10 to 9.3 ± 1.4 out of 10 (P < .001). CONCLUSION Judicious repeat lateral sphincterotomy cures recurrent chronic fissures with minimal risk of incontinence.

How to Manage the Patient with Early-Age-of-Onset (<50 years) Colorectal Cancer?

Colorectal cancer rarely occurs before the age of 50. When it does, it is often advanced and aggressive. There may be predisposing genetic and immune factors that lead to its origin. Genetic counseling is indicated for all patients younger than 50 with colorectal cancer. Before surgery, the tumor and the patient must be evaluated as fully as possible, so that optimal treatment, follow-up, and surveillance are used.

Standards for Local Recurrence Rates in Both Open and Laparoscopic Rectal Cancer Surgery. How do you Measure Up

Local recurrence of rectal cancer is the result either of potentially removable tumor cells left in situ or cells already disseminated to areas where surgery cannot reach them. The first scenario infers inadequate surgery, the second implies unfavorable biology. Surgeons who operate for rectal cancer must know local recurrence rates in their patients, and be able to relate them to outcomes achieved by others. We have performed this study to facilitate such a comparison. Methods: Systematic review of the literature from 1990 to 2010 was performed for publications which reported local recurrence after proctectomy for rectal cancer. Inclusion criteria were: studies of more than 80 patients and local recurrence stratified by histopathologic stage. Pooled local recurrence rates were tabulated by 5 percentile levels, stratified according to TNM stage (I,II,III) and surgical technique (total mesorectal excision or standard), as well as laparoscopic versus open. Results: Thirty-six studies comprising 16425 patients were pooled for final analysis: Mean follow-up is 40.9 months (1.3-188mths). The table shows local recurrence stratified by tumor biology (stage), operative technique (total mesorectal excision vs. standard) and operative approach (open vs. laparoscopic). The percentiles provide standards against which surgeons can compare their own outcomes Conclusion: Oncologic outcome of the treatment of rectal cancer is the result of interaction of therapeutic expertise and tumor biology. The percentile tables allow the use of local recurrence rates as an indirect parameter of surgical quality.

Colorectal surveillance after segmental resection for young-onset colorectal cancer: is there evidence for extended resection?

Although sporadic colorectal cancer (CRC) usually occurs in patients aged over 50, recent evidence suggests that the incidence is increasing in younger patients. Such patients are theoretically at high risk of metachronous neoplasia and may be candidates for extended prophylactic colectomy. This study aimed to define the risk of metachronous cancer/adenomas during follow‐up of younger patients who underwent segmental colectomy for CRC.

Should bypass or stoma creation be undertaken for unresectable stage IV colorectal carcinoma

When patients with stage IV colorectal cancer are deemed to have an unresectable primary colorectal cancer or extensive metastases at surgery, bypass or stoma creation may be the only surgical options. Whether this surgical approach provides extra months of life or instead leads to prohibitive post‐operative morbidity and mortality has not previously been well characterized. This study was conducted to evaluate early and long‐term outcomes for stage IV colorectal cancer patients with unresectable primary tumour.

Su1612 Long Term Outcomes of Continent Ileostomy Created in the Pediatric Age Group

Background/aim: Continent ileostomy (CI) is a surgically created intra-abdominal pouch in patients with a permanent end ileostomy. CI is one of the few surgical options that may be offered to patients who were fated to live with a permanent ileostomy, but want to avoid a stoma appliance at any cost. Data about durability, clinical and functional outcomes of CI created in pediatric patients are limited. In this study, we aimed to evaluate our 36-year operative experience on CI in pediatric patients with a 21 year median follow-up. Methods: Pediatric (≤21 years)* patients undergoing a CI procedure at a single institution from 19732009 were identified. CI revisions that required pouchotomy or re-construction following total or partial excision of CI were defined as major and those that did not require bowel resection were defined as minor revisions. CI failure was defined as excision of the pouch and formation of an end ileostomy. Results: 49 patients (26 male), median age 18 (12-21) years and median body mass index 22 (16-38.6) underwent CI. 10 (20%) patients had a CI at the time of total proctocolectomy. 12 (25%) patients underwent conversion of an ileoanal pouch (IPAA) to a CI. The majority of the patients (n=39, 80%) had ulcerative colitis or indeterminate colitis at the time of CI creation; however Crohns disease were diagnosed in 4 patients postoperatively. There were no intra-operative or early post-operative deaths. One patients who underwent CI excision seven years after CI creation due to complicated Crohns disease, died ten years after CI excision. Median follow-up time was 21(range 1-38) years. Valve slippage (33%), small bowel obstruction (25%), pouchitis (25%) and fistula (23%) were the common complications (table). 37 patients (76%) underwent at least 1 revision procedure after CI creation. 36 (74%) patients underwent major revision and 6 (12%) patients underwent minor revisions. Median pouch intubation was 6 (range 4-10) times per day. Pouch failure occurred in 9 (18%) patients with 7 out of 9 cases being due to complications from Crohns disease. Conclusions: CI is safe and durable in pediatric patients. Development of Crohns disease after CI creation seems to be a risk factor for failure. Since likelihood of further revisions is high, patients with CI should be followedup regularly. * Council on Child and Adolescent Health. Age Limits of Pediatrics. Pediatrics 1988;81:736. Primary diagnosis, complications and follow-up details